New Brunswick

Moncton inquest into teen's death in hospital concludes with 7 recommendations

A coroner's inquest into the death of a homeless teen in a hospital psychiatric unit concluded Wednesday in Moncton with the jury issuing five recommendations.

Kaytlyn Hemsworth, 19, died by suicide in April 2023

A large sign says "Dr. Georges-L.-Dumont University Hospital Centre" with a four-storey grey concrete building in the background.
The inquest examined the death of Kaytlyn Hemsworth, who was a patient in the Dr. Georges-L.-Dumont University Hospital Centre in Moncton. (Shane Magee/CBC)

WARNING: This story deals with suicide

A coroner's inquest into the death of a homeless teen in a hospital psychiatric unit concluded Wednesday in Moncton with the jury issuing five recommendations.

The inquest was examining the death of Kaytlyn Hemsworth at the Dr. Georges-L.-Dumont University Hospital Centre on April 11, 2023. The jury ruled the 19-year-old died by suicide.

The jury heard Hemsworth was supposed to be checked every 15 minutes. However, a police officer said a review of surveillance video indicated no one had checked on her for an hour and a half before she was found in a closet by a nurse.

Inquests are held to hear facts about a person's death and determine the manner of their death, but not to assign blame. Jurors can issue recommendations aimed at avoiding similar deaths in the future.

A smiling woman with long dark hair.
Kaytlyn Hemsworth died April 11, 2023, at the Dr. Georges-L.-Dumont University Hospital Centre in Moncton. (Passage Funeral Home)

Deputy Chief Coroner Emily Caissy presided over the inquest which began with jury selection Monday afternoon at the Moncton courthouse. 

Jurors issued five recommendations, while Caissy added two more. 

Increased patient monitoring recommended

The recommendations include having a dedicated staff member for suicide prevention, who could identify risk factors and carry out wellness checks.

"This would eliminate lapses caused by multi-tasking or staff shortages," jurors wrote. "It would also reduce [the] burden on nursing staff when they need to focus on patient care."

Another jury recommendation called for reducing the patient-to-nurse ratio, which jurors heard is currently four to six patients per nurse. The jury also recommended patients wear a device that could continuously monitor their vital signs, something less invasive than 24/7 video surveillance. 

Jurors also recommended keeping doors and windows clear of obstructions and implementing changes to policies and procedures at psychiatric units across the province.

Woman with long brown hair standing in front of the courthouse in Saint John.
Emily Caissy was the coroner presiding over the inquest. (Roger Cosman/CBC)

Caissy recommended equipping all nursing stations in psychiatric units with a special knife to help if a person is hanging.

Officials from Vitalité Health Network, which operates the Dumont hospital, testified a new form has been in use since February 2024 to document that regular checks of patients are completed. Caissy's second recommendation was to ensure the form is properly used.

Several medical staff testified about Hemsworth's care. 

Dr. Danny Godin, an emergency room physician, was the first witness called Monday. He testified he saw Hemsworth in the ER on March 14, 2023.

Godin described her as agitated, moving from one strong emotion to another without any logical transition. Godin said he saw signs of self-harm and considered her in a crisis state. 

He admitted Hemsworth under a Form 1, which allows a person to be held against their will for 72 hours. 

Psychiatrist Dr. Jacques-Andre Godbout evaluated Hemsworth and determined she should be held. Hemsworth was placed in a room and was supposed to be checked every 15 minutes. 

Godbout also told jurors the emergency room was supposed to have a psychiatric nurse on duty, but there wasn't one March 14.

Dr. Colette Aucoin, a psychiatrist at the Dumont, testified about several assessments of Hemsworth during the month she spent in the hospital before her death.

Aucoin testified that there were discussions of lifting the hospitalization requirement as Hemsworth no longer seemed to pose a risk to her own safety. Aucoin said there were discussions of longer-term plans like getting an apartment, going to college and getting a cat. 

Experienced periods of homelessness

Aucoin said there was no question that psychotherapy treatment for Hemsworth would need to continue once she was released, and a need for accommodations as she had been homeless at several points.

"Every time she found herself homeless, she tried to commit suicide," Aucoin testified.

The psychiatrist said Hemsworth had a substance use disorder related to use of illicit drugs, borderline personality disorder, ADHD and an unspecified mood disorder.

On the morning of her death, Aucoin said Hemsworth spoke of frustration with the food and the death of a friend days before by suicide. Aucoin said her patient seemed to be managing her emotions better and she didn't have reason to worry about her well-being.

Vitalité reviewing recommendations

The inquest recommendations are not binding. 

Rino Lang, Vitalité's assistant vice president for professional services, said in a statement to Radio-Canada after the inquest concluded that the health authority worked closely with the coroner's office and its investigation.

"We are committed to carefully reviewing the coroner's recommendations and remain dedicated to providing a safe and compassionate care environment for all our patients," Lang said.

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With files from Frédéric Cammarano